Fillable Appeal And Hearing Request (Page 4 of 4) in pdf

Continuing services

To keep getting the service while you wait for your Appeal or Hearing, you must:



Have already been getting the service before it was denied,



Request for the service to be continued by checking Box 4 on page 1 of this form, and



Ask for an Appeal and/or Hearing within 10 days from the “Date of Notice” or by the “Effective Date,”

whichever is later, shown on the Notice of Action or Notice of Appeal Resolution.

If we do not change our decision or the Hearing judge supports our decision, you may have to pay for services you

get after the “Effective Date” shown on the Notice of Action or Notice of Appeal Resolution.

Can someone represent me at the Hearing?

You may have a friend, family member, advocate, doctor or lawyer in the Hearing to help you. We cannot pay for

the cost of a lawyer, but if you want one you may try the following options:



Call the Public Benefits Hotline at 1-800-520-5292 (TTY 711) for advice and possible representation. The

Public Benefits Hotline is a program of Legal Aid Services of Oregon and the Oregon Law Center.



Call the Oregon State Bar Association at 1-800-452-8260 and ask about free or low-cost legal services.

If you want someone to represent you at the Hearing, give us their contact information on your request or let the

DMAP Hearing Representative know when they call you before the Hearing.

Other things you can do

Note: Doing any of the following things will not give you more time to request an Appeal or Hearing.

1. You or your doctor may send documents that explain why the decision was wrong to the address listed in the

Questions section of the Notice of Action or your Notice of Appeal Resolution.

2. You may ask your doctor about other ways to treat your condition.

3. You may get the information used in making this decision. To get a copy, call Customer Service at the phone

number listed in the Questions section of the Notice of Action or your Notice of Appeal Resolution.

4. If the final decision on your Appeal or Hearing is that the service is not covered, you may still receive the

service and pay for it yourself. Ask your provider about this choice. Your provider will have you sign a form

that states you understand the service is not covered and you are agreeing to pay for it. The form will show the

amount your provider will charge you and information about other costs, such as hospital or lab costs.

Final order by default

You may lose your right to an Appeal or Hearing if you:



Do not ask for an Appeal or Hearing on time, or



Withdraw your request, or



Miss your Hearing.

If you lose your right to an Appeal or Hearing your Notice of Action will be the final decision, called a “final order

by default.” You will not get a separate final order by default. If you do not request an Appeal or Hearing, the

“final order by default” will become effective 45 days after the date of this notice. The reviewer will consider the

relevant portions of the agency’s file, including all of the materials you submitted in this matter as the record. The

record is used to support the decision upon default. You may challenge the final order by default by filing a

petition in the Oregon Court of Appeals (ORS 183.482). You must do this within 60 days of the Date of Notice on

the first page of your Notice of Action. If you withdraw a Hearing request or miss your Hearing, the appeal

deadline will be set out in the dismissal order.

DMAP 3302 (Rev 1/2014)

Appeal And Hearing Request Page 4

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